Qiao et al.

BMC Medical Education 2014, 14:79

http://www.biomedcentral.com/1472-6920/14/79

RESEARCH ARTICLE

Open Access

Using cognitive theory to facilitate medical

education
Yu Qi Qiao1,4, Jun Shen1,4, Xiao Liang1,4, Song Ding2,4, Fang Yuan Chen3,4, Li Shao4,5, Qing Zheng1,4
and Zhi Hua Ran1,4*

Abstract
Background: Educators continue to search for better strategies for medical education. Although the unifying
theme of reforms was increasing interest in, attention to, and understanding of the knowledge base structures, it
is difficult to achieve all these aspects via a single type of instruction.
Methods: We used related key words to search in Google Scholar and Pubmed. Related search results on this topic
were selected for discussion.
Results: Despite the range of different methods used in medical education, students are still required to memorize
much of what they are taught, especially for the basic sciences. Subjects like anatomy and pathology carry a high
intrinsic cognitive load mainly because of the large volume of information that must be retained. For these subjects,
decreasing cognitive load is not feasible and memorizing appears to be the only strategy, yet the cognitive load makes
learning a challenge for many students. Cognitive load is further increased when inappropriate use of educational
methods occurs, e.g., in problem based learning which demands clinical reasoning, a high level and complex cognitive
skill. It is widely known that experts are more skilled at clinical reasoning than novices because of their accumulated
experiences. These experiences are based on the formation of cognitive schemata. In this paper we describe the use of
cognitive schemata, developed by experts as worked examples to facilitate medical students learning and to promote
their clinical reasoning.
Conclusion: We suggest that cognitive load theory can provide a useful framework for understanding the challenges
and successes associated with education of medical professionals.
Keywords: Working memory, Cognitive load theory, Schemata, Clinical reasoning, Worked example, Problem based
learning, Clinical presentation curriculum

Background
Medical education has changed significantly over time. The
changes are linked not only to changes in educational technology and the advancement of medical knowledge, but
also in educational concepts and curricula. From the 1940s,
key principles and practices of the discipline-based model
were questioned by educators. In 1944, Goodenough advocated for a reduction in basic science detail which seemed
* Correspondence: zhihuaran@vip.163.com
1
Division of Gastroenterology and Hepatology, Ren Ji Hospital, School of
Medicine, Shanghai Jiao Tong University, Shanghai Institute of Digestive
Disease, 160# Pu Jian Road, Shanghai, China 200127
4
Internal medicine teaching and research office, Ren Ji Hospital, School of
Medicine, Shanghai Jiao Tong University, 160# Pu Jian Road, Shanghai, China
200127
Full list of author information is available at the end of the article

to clutter up the students mind and deaden interest [1].

Sinclair [2] noted that medical students are often attracted
to medicine by a sense of idealism, but the premedical,
preclinical and clinical sequence of instruction discourages
them.
An early wave of innovation saw a revised curriculum
which focused on organ systems. This may be one of the
earliest examples of an attempt to better integrate the curriculum. Two different models followed which then catalyzed significant changes in medical curricula. One is
problem based learning (PBL), which has been in use since
1971 and still remains popular in many medical schools.
The other is the clinical presentation (CP) based model,
which has been used since 1991.

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Educators continue to search for better strategies for

medical education. Papa et al. [3] detail the unifying theme
of reforms: increasing interest in, attention to, and understanding of the knowledge base structures and cognitive
processes that characterize and distinguish medical experts and novices. There are three main aspects to this
theme: (1) more attractive courses; (2) well organized
knowledge; and (3) proper guidance for different students.
Although these aspects are relatively independent, they
are often confused by educators. Attractive courses are
not necessarily effective, and effective training is not always interesting. It is difficult to achieve all these aspects
via a single type of instruction.
In this paper, we aim to answer several questions: (1)
What is the basic step in medical learning, to think or to
memorize? (2) Why do some curricula seem attractive,
but prove not to be effective? (3) What are the differences
between novices and experts? (4) How can novices become experts, and how best can novices be given instruction? Answers to these questions are complex and widely
debated. However, we argue that cognitive load theory
proposed by Sweller et al. [4-8] holds answers to these
questions. Cognitive load theory is based on human cognitive architecture and assumes a limited working memory
capacity. We argue that when designing instruction, it
must be taken into more explicit consideration.

Methods
PBL has been shown to be less effective than expected in
teaching of internal medicine [9]. We aimed to determine
the reasons for this. As a first step, key words linked to
medical education were selected and used in a literature
search. These included medical education, curriculum,
problem based learning, and clinical reasoning. Advantage, disadvantage or limit were also used when needed.
For the second step, we added several other key words,
closely related to cognitive load theory. They included
cognitive load, schema, worked examples and working
memory. We used these key words to search in Google
Scholar (http://scholar.google.com) and Pubmed (http://
www.ncbi.nlm.nih.gov/pubmed/). Related search results
on this topic were selected for discussion. The full text of
articles was acquired from the open internet proxy service
of Shanghai Jiao Tong University and the library of the
School of Medicine, Shanghai Jiao Tong University. The
research protocol was approved by the Ethics Committee
of Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong
University.
Results and discussion
Memorizing: a basic step in learning

What is the most basic step in medical learning? To make

students thinkers rather than memorizers was the hallmark of the discipline-based curricular movement, which

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dates back to the late 19th century. In 1898, Sternberg

echoed the importance of thinking in his American Medical
Association (AMA) presidential address [3]. Over the next
hundred years, educators continually made efforts to support this view and the importance of thinking over memorizing. However, we contend that to be a thinker, one first
needs to be a memorizer. Although it may not follow that a
good thinker should be a good memorizer, a good thinker
most likely needs to draw on a wide and deep reservoir of
memorized knowledge. In Swellers words, the more sophisticated and knowledgeable the learner, the more complex will be the elements he or she is dealing with [10]. An
element is defined here as material to be learned.
The definitions of short-term memory (STM) and longterm memory (LTM) indicate the different time spans of
the information retention associated with each. STM retains information for just a few seconds. LTM can hold information for several days or decades. Working memory
(WM) stores task-relevant information and involves the
temporary storage of information that is being processed
in any of a range of cognitive tasks [11,12]. Because of
temporary storage, WM was once considered as a function of STM. Now, many researchers believe STM is in
fact a component of WM, and there are other mechanisms based on skilled use of storage in LTM. Ericsson
and Delaney used the term long-term working memory
(LTWM) to refer to information that is stored in stable
form, but could be retrieved temporarily by means of cues
in STM [13]. Baddeley considered this as an interactive
mode between LTM and WM rather than a new type of
WM per se [14].
As LTM has been demonstrated as an important source
of WM, knowledge in LTM should not be neglected. In
medical education, acquisition of declarative knowledge
depends on memory, especially LTM, and LTM can also
directly affect actions [14]. Procedural or skills based
knowledge should be retrieved from LTM when needed
[15]. Problem-solving performance is dependent on knowledge of specific areas, so clinical reasoning ability cannot
be separated from LTM. As Clark et al. [16] described,
novices can attend the problem-solving process, but they
may learn almost nothing. Memorizing should be regarded
as a first basic step in learning as it gives a firm foundation
for further learning and practice. However, promoting
memorizing remains a challenging task.
Cognitive load theory: a framework for proper instruction

WM capacity (WMC) is limited to holding approximately

seven (plus or minus two) elements (or chunks) when processing information [17]. Studies have indicated that WMC
limits students performance in science learning and problem solving [18-20]. Similarly, cognitive load theory supports the idea that WM limits the amount of information
an individual can process [5,21]. The theory suggests that

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there are two main types of cognitive load, intrinsic and extraneous load. Germane load can further be considered as a
supplementary type.
Intrinsic load is based on the interactivity of elements in
learning materials. As it refers to the nature of learning
materials, it is constant for a given area. In some subjects,
interactions between many elements must be learned, and
the intrinsic cognitive load will be high [5,21,22]. Intrinsic
cognitive load depends on a learners prior knowledge
[23]. When many new elements appear together in learning materials, novices may experience learning difficulties
even if the interactivity of elements is low. The learning
process may involve combining single elements into
chunks. These chunks are defined as cognitive schemata
and can be stored in LTM [24]. Another way of viewing
cognitive schemata is to see them as highly organized information or knowledge. Over time, as prior knowledge
forms into schemata, expertise increases, and the intrinsic
load can be reduced.
Total cognitive load, the working memory load experienced by learners, is not only based on the intrinsic load,
but also linked to the teaching methods employed. When
these do not promote learning, they can be defined as extraneous cognitive load. Extraneous cognitive load arises
from inappropriate guidance that cannot contribute to the
construction of cognitive schemata [24]. In contrast with
extraneous cognitive load, germane load arises from the
process of forming cognitive schemata. Germane load was
added to the cognitive load framework as a supplement [4].
In recent explanations of the theory, germane load was
termed as germane resources and closely related to intrinsic
load [5,6]. As there is no necessity to include germane load
in specific empirical results, Kalyuga redefined it as working
memory resources dealing with intrinsic load [25].
In medical learning, considering only the large volume
of information, the challenges associated with learning can
be very high. For clinical reasoning education, the cognitive load becomes higher because of the high interactivity
of elements. The large amount of information and high intrinsic cognitive load can explain why medical learning is
most often a challenge. Learning processes could be affected when the cognitive load exceeds the limit of WMC
[26]. Medical students have to take considerable time in
memorizing and understanding the unrelated learning
materials. One solution is to decrease the extraneous cognitive load in learning materials [26].
Moving to our second question: Why do some curricula
seem attractive, but not effective? High intrinsic cognitive
load causes difficulties when studying medicine because of
the large volume of information. When inappropriate
teaching methods are used (e.g., guidance integrated with
different disciplines or problem based exploration) this
will serve to even further increase the extraneous cognitive
load without decreasing the burden of intrinsic load.

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Although cognitive load theory has not always been explicitly considered, there is evidence for its effectiveness.
In the 1950s, the Western Reserve School of Medicine initiated the first organ-system curriculum [27]. Educators
aimed to help students integrate knowledge of systemoriented functions and malfunctions. This reform failed
because while it appeared to integrate basic science with
clinical knowledge, learners struggled to achieve this integration. As the amount of information was not reduced
and interacting elements were added to the curriculum,
extraneous cognitive load became untenably high, especially for junior medical students. Students in the early
years of their degree programs have limited background
knowledge of medicine, and are not able to effectively
chunk the large number of elements into schemata. The
cognitive load of the organ-system framework most likely
exceeded the students WMC. The demands of that
process may be viewed as analogous to expecting novice
foreign language learners to readily master grammar.
PBL focuses on clinical cases and is widely used in medical education. There has been considerable debate about
PBL, and attitudes towards the approach vary considerably. Literature suggests that it can be used as an effective
approach, but this is not always the case. Patel et al. found
that PBL students were less accurate in diagnosis and
made more conceptual errors than their more traditionally
trained counterparts [28]. Albanese et al. carried out a
meta-analysis focusing on PBL and its effectiveness [29].
They found that PBL students spent more time studying,
but that their basic science exam scores were lower than
students who were being trained using other methods. Although PBL students achieved better scores for their clinical performance, they were found to order significantly
more unnecessary tests for their patient, which means a
higher cost with less benefit. In Berksons meta-analysis,
similar conclusions were reached [30]. Colliver reviewed
PBL literature and noted no convincing evidence that PBL
improves students knowledge base and clinical performance [31]. While Kirschner debates the effect of PBL [9],
Sanson-Fisher et al. highlight a lack of evidence supporting
the superiority of PBL over traditional methods [32]. PBL
is innovative, but has yet to meet the requirements of
evidence-based practice. Sweller et al. emphasize that PBL
may teach students how to find information, but it does
not reduce the relevant information that is ultimately required to be assimilated [33]. A more recent meta-analysis
suggests that unassisted discovery does not benefit learners
[34]. Conversely, feedback, worked examples, scaffolding,
and elicited explanations might work.
PBL aims to improve the hypothetico-deductive reasoning (HDR) of students. However, HDR brings with it a
high cognitive load, which needs some degree of prior
background knowledge and some basic skills. Students
may face the same challenges in PBL as in the organ-

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system curriculum. Before acquiring basic knowledge, the

cognitive load is high and materials might be hard for students to understand. This can explain why PBL students
spend more study hours and make more conceptual errors. Haeri et al. did not recommend widespread use of
HDR [35]. Although the full use of PBL is not advocated
for medical curricula, it should be noted that this does not
mean that PBL is totally outdated or inappropriate. It does
have some uses in medical education, especially if understood in light of the cognitive load theory, a point to which
we return later.
Schemata: distinguishing experts from novices

Inappropriate instruction cannot promote learning, especially in novices. Before giving proper instruction, we
consider the differences between novices and experts.
While a person may have the capability to memorize
Shakespeares dramas, it does not mean that s/he would
then have the writing skills of Shakespeare! Could one
learn more when memorizing more? Although this
seems logical, it may not be accurate. A study of physicians has shown a positive relationship between memory
for numerical laboratory data and expertise [36]. However,
when participants were informed at the outset that a
memory test would be given, the difference between experts and students was no longer reliable. This retrieval
task showed that there is no significant memory difference
between experts and students, but experts can memorize
related information simultaneously. While storing information in LTM is the basic step of learning, Paas et al.
suggested two other critical mechanisms: schemata acquisition and the transfer of learned procedures from controlled to automatic processing [37]. Evidence showed that
domain specific knowledge in the form of schemata is the
primary factor distinguishing experts from novices in
learning and problem-solving skill [21].
Schemata consist of highly organized knowledge and information. According to Elstein, knowledge organization
and schemata acquisition are important in developing expertise [38]. For example, experiments suggest that chess
experts can remember 50,000 game positions. This superior memory is thought to be mediated by the familiar and
meaningful configurations of the chess pieces [39]. A
chess master stores a large amount of information regarding the specific patterns of chess pieces in LTM, and
memory representations allow for the rapid recognition of
patterns in a presented chess position. Cooke et al. contended that skilled chess players encode chess positions in
terms of high-level descriptions of their structure [40].
The research on chess players suggests two aspects of
organized knowledge in LTM: (1) Using organized knowledge can increase the speed of retrieval from LTM; (2)
After a training period, a large amount of organized knowledge relating to a specific area can be stored in LTM.

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New information can be organized more quickly by experts

in a specific field. A schema is a cognitive construct that organizes the elements of information according to how they
will be processed [21]. In Swellers cognitive load theory,
schemata could reduce elements interactivity, and thereby
reduce the intrinsic cognitive load. According to Ericsson
et al., the bottleneck for retrieval from LTM is the lack of
retrieval cues that relate to the desired item stored in LTM
[13]. Schemata represent a higher level of organized knowledge than a simple collection of lower-level components
[41]. Although organized knowledge cannot increase the
retrieval cues, it can reduce the need for such cues. Schemata that contain automated procedural knowledge, can be
considered as a whole to be retrieved together. Learners
with higher levels of knowledge can retrieve appropriate
schemata and generate more appropriate solutions.
Now we can also explain why senior doctors are better at clinical reasoning than novices. Clinical reasoning
is complex and requires breadth of knowledge, knowledge organization and retrieval ability, and that each of
these aspects work together. Doctors will always require
a broad perspective of organized knowledge for their
reasoning. Schmidt describes how experts may have access to extensive case knowledge, but this knowledge remains encapsulated until needed [42]. Rikers et al.
showed that encapsulated knowledge plays a very important role in specialists clinical reasoning [43] and
that this is very different from the clinical reasoning of
senior medical students. While senior medical students
could use basic scientific knowledge to explain a
phenomenon, specialists made more accurate diagnoses
even in areas beyond their own specialty.
Norman reviewed research focusing on clinical reasoning [44]. Evidence suggests that expertise is distinguished
by acquisition of illness scripts, decision trees, symptoms,
disease probabilities, semantic qualifiers and more (or less)
basic science. Clinicians appear to move through three different kinds of mental representations, from basic mechanisms of disease to illness scripts to exemplars derived
from experience [45]. The developmental theory of medical expertise is based on increasing clinical experience.
Kyllonen et al. found that reasoning correlated highly with
general knowledge [46]. Experience might be the most significant difference between novices and experts. Normans
work suggested to us that focusing on clinical experts
might be a useful way to promote clinical reasoning. To
study from clinical experts is to study their experiences.
The increasing store of experiences results in more schemata formation. Merrinboer et al. described learning as
the construction and automation of such schemata [8]. A
randomized trial by Blissett et al. focused on schema based
teaching [47]. It showed such instruction could improve
retention of structured knowledge and diagnostic performance among novices. To study clinical experience

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might be easier and more effective than to study reasoning

strategies since there is most likely no one particular reasoning strategy used.
Proper instruction helps novices become experts

How can we make novices become experts? How can

we give proper instruction to novices? In a traditional
discipline-based curriculum, students need to memorize
a large volume of information presented in no particular
order. They have to integrate this information into clinically meaningful knowledge. Educators are always looking for ways to lower the burden of remembering and
trying to integrate information into a logical order that
is easy for students to learn. Worked examples may be a
good method for novices. This involves presentation of
a real task process rather than just explaining how it
works. When giving worked examples, the experience is
contained. Imitation is a good way of learning with the
lowest cognitive load. It is reasonable to give an example first and then explain why. Tuovinen et al. found
that students with no previous domain familiarity could
substantially benefit from worked examples in comparison to exploration [44]. Sweller et al. also demonstrate
how worked examples can be an effective way to reduce
extraneous cognitive load [4]. They showed worked examples with annotations regarding crucial features were
helpful for students in applying schemata in problemsolving [48,49]. A study of novices showed that students
who studied applications of Bayes theorem in exampleexample or example-problem conditions performed better than their peers who studied the applications in
problem-example or problem-problem conditions [24].
In medical education, it is not easy to form organized
knowledge through clinical reasoning strategy training
[44]. However, educators at the University of Calgarys
Faculty of Medicine (UCFM) used the idea of worked
examples to achieve this. They shared the experience of
experts using developed schemes with medical students
[3,50]. They assessed the advantages and disadvantages
of the former medical curriculum to revise and form a
new curriculum. By 1991, the clinical presentation curriculum (CPC) was ready for use and consisted of 120
clinical presentations [50]. Since the aim of learning is
to know what to do, each presentation described the appropriate clinical procedures for dealing with particular
conditions (e.g., loss of consciousness/syncope). Schemata outlined how experienced physicians differentiated
one cause from another. The presentations were developed by medical experts and the structure was based on
how real patients present to physicians. Current knowledge, principles of adult learning, clinical problem solving,
community demands and curriculum management were
taken into consideration for the curriculum structure [50].
These worked examples facilitated the students learning.

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In 1998, educators from UCFM carried out an analysis

of the use of CPC. They found that it generated less stress
than other curricula, despite an equivalent workload [51].
In 2009, a comparison of a 3- and 4-year curriculum was
made by Lockyer et al. [52]. CPC was applied in a 3-year
curriculum at UCFM. The results showed no significant
difference between students from UCFM and those following a 4-year curriculum. Students from UCFM were
saving about 3 months of medical study time to meet the
same standard. Although UCFM have provided the only
data based evidence of CPC to date, other researchers
have given their support to CPC. Tsai introduced CPC
and supported its use in Taiwan [53]. Haeri et al. also recommended CPC as a more appropriate choice than PBL.
CPC may offer a preferable way of training, but its focus is
on clinical education rather than on preclinical work or
basic sciences [35]. Worked examples can foster diagnostic knowledge [54]. van den Berge et al. showed that novices who studied worked examples of electrocardiograms
(ECG) performed better on a retention test [55]. Worked
examples can also be applied to the acquisition of visual
perceptual skills, and have even been used in more complex skills training, such as bronchoscopy and catheterbased cardiovascular interventions [56,57].
Returning to PBL, we note that this approach has been
used in a range of different areas. In medical education,
PBL is considered an appropriate way to promote HDR
abilities and it has been implemented in many curricula
[58]. PBL has been widely used as a way to encourage exploration, but many scholars argue that its use in medical
education needs reconsideration [9]. Today there are still
many PBL curricula used in medical schools around the
world. A PBL curriculum will typically give simulated scenarios of real clinical work, with minimal guidance given
beforehand. It is a student centered active learning activity
which strives to promote self-study [3]. However, there is
no evidence to show that PBL students perform better
than students following a traditional curriculum. This may
be because of the inappropriate implementation of PBL.
As PBL is an HDR process with feedback, it has to be supported by sufficient related knowledge. Novices have yet
to acquire this knowledge. They lack the knowledge to
complete the process. In early stages of medical education,
basic science and preclinical courses are the main components of learning. Memorizing knowledge plays an important role at that stage. There is a large amount of new
information in anatomy, pathology, physiology and biochemistry. The task is difficult because of the high volume
of information [10]. Using PBL at that stage cannot reduce
the intrinsic load. HDR with high interactivity of elements
might even increase the extraneous cognitive load. This
could explain why PBL students achieve lower scores in
basic science [29]. For senior medical students, the situation is quite different, especially when they begin their

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internships. Senior students have more relative knowledge

than novices, and they will be exposed to more clinical problems than their junior peers. As formation of schemata
(increasing expertise) can reduce the intrinsic cognitive load,
partially or minimally guided instruction can be effective for
senior students and residents under supervision [16].

Conclusion
Medical education reform is ongoing. The motivation
underpinning this reform has not changed over time. Although different methods have been trialed in medical education, memorizing is still an important step, especially for
the basic sciences. According to cognitive load theory, the
intrinsic cognitive load of subjects like anatomy or pathology originates mainly from the large volume of new information. Methods to decrease extraneous cognitive load
might not be effective in the case of these subjects. To
store more information in LTM might be the only feasible
solution. Learning challenges will increase when cognitive
load is high. Inappropriate use of educational methods can
also increase the extraneous cognitive load. When cognitive load exceeds WMC, it will negatively affect the learning processes. The failure of the organ-system curriculum
described in this paper gives an example of this negative
overloading effect. Similarly, the inappropriate use of PBL
will lead to the same outcome. These curricula seem attractive and innovative, but are not effective. Clinical reasoning is a complex process with a high intrinsic cognitive
load. Experts are skilled at clinical reasoning when compared with novices. We have emphasized that this is because of their experiences. These experiences are based on
the formation of cognitive schemata. We described the application of such schemata where experts have developed
worked examples for students to facilitate their study. Ultimately, this may promote clinical reasoning. Although
the full use of PBL is not recommended in medical education, it could be effectively used as a supplementary approach with senior students to facilitate their exploration
and self-study.
Competing interests
The authors declare that they have no competing interests.
Authors contributions
QYQ and SJ have made substantial contributions to the conception and design
of this paper. QYQ drafted the manuscript. DS and LX supplied the teaching
materials of minimal guidance and contributed to the discussion in the article.
SL and CFY supplied the materials related to the clinical reasoning courses and
also contributed to the discussion. RZH revised the manuscript critically for
important intellectual content. ZQ revised the manuscript based on reviewers
reports. All authors read and approved the final manuscript.
Acknowledgments
This article is supported by China Association of Higher Education 12th Five
Year Plan Educational Program (No. 11YB142); Chinese Medical Association
Education Branch Educational Program (No. 2012-ZYY-13); School of Medicine,
Shanghai Jiao Tong University, Educational Research Grant (No. ZD120909).

Page 6 of 7

Author details
Division of Gastroenterology and Hepatology, Ren Ji Hospital, School of
Medicine, Shanghai Jiao Tong University, Shanghai Institute of Digestive
Disease, 160# Pu Jian Road, Shanghai, China 200127. 2Division of Cardiology,
Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, 160# Pu
Jian Road, Shanghai, China 200127. 3Division of Hematology, Ren Ji Hospital,
School of Medicine, Shanghai Jiao Tong University, 160# Pu Jian Road,
Shanghai, China 200127. 4Internal medicine teaching and research office, Ren
Ji Hospital, School of Medicine, Shanghai Jiao Tong University, 160# Pu Jian
Road, Shanghai, China 200127. 5Ren Ji Clinical Medical College, Ren Ji
Hospital, School of Medicine, Shanghai Jiao Tong University, 160# Pu Jian
Road, Shanghai, China 200127.
1

Received: 22 November 2013 Accepted: 9 April 2014

Published: 14 April 2014
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doi:10.1186/1472-6920-14-79
Cite this article as: Qiao et al.: Using cognitive theory to facilitate
medical education. BMC Medical Education 2014 14:79.

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